Mercury Amalgam-Gold Crown Interaction Paediatric Dentistry

LETTERS

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Staining from silver nitrate Sir, — We wish to highlight an unusual gingival aspect of both incisors. Other methods of achieving case where hypocalcified enamel became The patient was referred to a consultant haemostasis should be considered in stained with silver nitrate subsequent to in restorative dentistry whose those situations where the enamel its use to achieve haemostasis during soft examination revealed that the enamel at structure may have been compromised. tissue biopsy. the gingival aspects was very thin and Alternatively, physical protective barriers A 16 year old girl was referred by her decalcified, consistent with tooth wear such as dental rubber dam could be used GDP for the excision of an unsightly due to erosion. The staining was attributed to protect the dental hard tissues from papillomatous swelling in the region of to the uptake of silver nitrate by the staining. the interdental papilla between the right porous enamel at the cervical margins Z. Sadiq, C. Moss and J. Stocker premaxillary incisors, which developed adjacent to the biopsy site. The patient Peterborough following a course of orthodontic underwent scaling, polishing and micro treatment. Examination revealed a 6 mm abrasion which produced some papillomatous type lesion with a improvement in appearance of the strawberry-like appearance at the dental affected teeth. The patient was also papilla between the right premaxillary offered further treatment including air incisors. The lesion was mobile with no abrasion and veneers. Although the use of evidence of periodontal pocketing. The silver nitrate is a method of achieving patient underwent excisional biopsy of haemostasis, this case highlights a the lesion under local anaesthesia limitation of its use. A careful history, outpatient care; during the procedure a examination and assessment of enamel silver nitrate stick was used to achieve status is important before deciding to use haemostasis. The patient subsequently chemical agents to achieve haemostasis in  developed a bluish staining (fig 1) at the procedures on the adjacent tissues.  Mercury amalgam-gold The amalgam and gold surfaces in the The key conclusion of both papers, i.e. patient’s mouth are all of different ages that restorative interventions provided crown interaction and may therefore be at least subtly within the General Dental Services in the Sir, — A patient attended surgery recently different in their composition. The UK do not appear to influence outcome, is for a routine inspection. A battery amalgam adjacent to the affected gold hugely disappointing, but sadly comes as driven/electric toothbrush was advised in crown has been replaced with a gold inlay little surprise to those within the Specialty order to reduce gingival recession and with no further effect to the gold crown. I of Paediatric Dentistry. That effective abrasion caused through too vigorous would be interested to hear whether restorative interventions for primary teeth manual toothbrushing. Accordingly, the anybody else has come across this exist is not in doubt. Stainless steel patient bought one and used just a few phenomenon, and also for any speculative crowns, for example, have demonstrated hours after inspection. explanations. There is also a toxological excellent longevity in a number of On self examination, the patient noticed dimension to the observation. A few free studies.3 The vital pulpotomy technique that a gold crown in the lower right standing milligrams of the amalgam has achieved over 90% success in virtually quadrant, which is adjacent to a silver filling and a scraping of the dull coat all studies that have investigated its amalgam, had lost its bright, highly deposit from the gold crown are available efficacy.4,5 In addition, contrary to the polished surface, and acquired a to interested parties for analysis. studies currently being discussed, there is tenacious, greyish appearance, akin to D. M. Cowen some evidence that a small minority of ‘brushed’ stainless steel. No such change Keighley practitioners within the GDS do achieve a occurred on any other gold crowns in the good outcome.6 However, the patient’s mouth even though they are fundamental question is this: why are the adjacent to other silver amalgams. On Paediatric dentistry levels of success reported in studies of polishing the affected gold crown, the Sir, — The recent papers investigating the individual techniques not being translated original yellow surface was exposed, but outcome of dental caries in primary molars by the majority of primary care appeared duller. We could speculate that raise important and fundamental questions practitioners into effective treatment the new electric tooth brush had possibly about dental services for children in the outcomes for children in the UK? liberated something from the silver United Kingdom and the authors are to be There can be little doubt that the amalgam, which was subsequently taken congratulated for taking the first steps authors’ assertion that ‘effective methods up by the gold crown; it was also noted into this potentially controversial area.1,2 I of preventing dental caries at the that the amalgam in question had have been asked to co-ordinate this individual and public health levels need to subsequently taken up a rather pitted consensus response on behalf of the be expanded’ is correct. However, in spite almost granular appearance. Consultants in Paediatric Dentistry Group. of considerable efforts to promote the

BRITISH DENTAL JOURNAL VOLUME 193. NO. 6 SEPTEMBER 28 2002 299 LETTERS

preventive message, dental caries is still at challenging questions: accidental trauma to the anterior 2/3rds of epidemic proportions in the young the tongue or lip either by the dentist or • Why is the success of restorative inter- children of our country and there has been the patient. The patient would also be ventions currently provided in the UK little change in its prevalence in the socially incapacitated after leaving the GDS apparently so poor when effective, primary dentition for nearly two decades. surgery. The use of rubber dam is the best evidence-based interventions are avail- In many parts of the country around way of protecting the patient from soft able? 50% or more of 5 year-old children have tissue damage, inhalation/ingestion of • Is the GDS the best place to provide den- dental caries experience, and, on average, debris and instruments and the tal treatment for a young child with those with decay have around four or unnecessary over-administration of drugs. caries or would improved access to spe- more decayed teeth by this age.7 The It also enhances the field of operation thus cialist paediatric dentistry services lead second of the two studies in question improving the quality of work done. Other to better outcomes? reinforces the findings of a previous study systems, such as Aqua-Vac, exist to • Does our current approach to DGA and which demonstrated that dental caries in overcome the difficulties described if the conscious sedation services for children children is associated with a high placement of rubber dam is impossible. need to be re-considered? morbidity.8 It is also important to P. L. V. Martin recognise that these studies employ design Now that the anaesthetic safety issues London features (i.e. retrospective record analysis) related to the delivery of conscious seda- which are likely to result in an tion and DGA have been fully addressed, Ethical selling undercounting of adverse events. The full what can be done to improve the quality of Sir, — The leader entitled Ethical selling - picture may be significantly worse. the dental care provided at the time of what is it? (BDJ 2002; 192: 423) There is clearly an urgent need to ensure these interventions, hence improving out- highlighted many of the qualms that that, where preventive strategies have come and reducing the need for repeat pro- practitioners have when broaching the failed to stop the development of clinical cedures? It is imperative that we respond to question of selling specific clinical disease, effective treatment interventions these challenges without delay. services. The final paragraph, which you are available. One potential route for S. A. Fayle quite rightly identified as crucial, raised primary care dentists is to refer young Leeds the question of what patients want and children with caries to a specialist centre. what they need not always being the same However, following implementation of the 1. Tickle M, Milsom K M, King D, Keamey-Mitchell P, thing. Once patients have been given Blinkhorn A S. The fate of carious primary teeth recommendations of the joint report of the among children regularly attending the General treatment options they often ask ‘is this CMO and CDO on the provision of dental Dental Service. Br Dent J 2002; 192: 2 19-223. treatment necessary?’ An explanation I general anaesthesia (DGA) services, 2. Milsom K M, Tickle M, Blinkhorn A S. Dental pain and give is that if the patient wants the end dental treatment of young children attending the paediatric dentistry services in many parts General Dental Service. Br Dent J 2002; 192: 280-284. result then the treatment is necessary. If, of the country are already under severe 3. Fayle S A. Faculty of Dental Surgery, Royal College of on the other hand, the patient does not pressure.9 While there has been a Surgeons. UK National Clinical Guidelines in want the end result, then the treatment is centrally driven shift of service provision Paediatric Dentistry. Stainless steel preformed crowns unnecessary. I suggest it is therefore the for primary molars. Int J Paed Dent 1999; 9: 311-314. from the primary care sector to the acute 4. Llewelyn D R. Faculty of Dental Surgery, Royal College patient’s responsibility to decide on hospital trusts, there has not been a of Surgeons. UK National Clinical Guidelines in necessity rather than the clinician’s. similar shift in central funding. Inability Paediatric Dentistry. The pulp treatment of the F. Haines primary dentition. Int J Paed Dent 2000; 10: 248-52. to expand hospital-based services to meet 5 Fuks A B. Holan G. Davis J M. Fidelman B. Ferric sulfate Truro demand has resulted in children with versus dilute formocresol in pulpotomized primary dental pain having to wait for long molars: long-term follow up. Ped Dent 1997; 19: Teeth whitening debate I periods of time before receiving treatment. 327-30. Sir, — I am totally baffled by all the issues 6 Wong F S L, Day S J. An investigation of factors Waiting time to consultation is already influencing the longevity of restorations in primary surrounding tooth whitening. Could more than one year in some centres.10 molars. J Int Ass Dent Child 1990; 20:11-6. history repeat itself with court cases Some of these children can be treated 7 Pitts N B. Evans D J. Nugent Z J. The dental caries concerning possible future adverse effects experience of 5-year-old children in Great Britain. using alternative approaches (such as Surveys co-ordinated by the British Association for like those of fluoride which can cause conscious sedation) but access to such the Study of Community Dentistry in 1999/2000. tooth mottling? Are tooth bleaching services is often very limited. For a Comm Dent Health 2001;18:49-55. agents cosmetics or pharmaceuticals? Is 8 Shepherd M A, Nadanovsky P, Sheiham A. The proportion, especially the very young, prevalence and impact of dental pain in 8-year-old bleaching necessary treatment for the DGA remains the only appropriate school children in Harrow, England. Br Dent J 1999; majority of patients who request it? What management strategy. It is essential that 187: 38-41. are the risks and does benefit outweigh these children have rapid access to dental 9 Department of Health. A Conscious Decision. A review risk? A significant number of my patients of the use of dental general anaesthetic and sedation conscious sedation and DGA services and services in primary dental care. HMSO 2000 have made enquiries about this treatment it is especially important that the planning 10 Consultants in Paediatric Dentistry Group. Personal and I would like to be able to give clearer and provision of dental care at these communications. advice backed by scientific evidence. Is 11 Harrison M, Nutting L. Repeat general anaesthesia for centres is of the highest quality to paediatric dentistry. Br Dent J 2000; 189: 37-9. DIY home bleaching considered to be safe minimise the risk of repeat DGA. 11 and legal? If so, Argos sell a Yotuel Urgent action is needed to improve the complete teeth whitening system for only quality of dental care available to young Rubber dammit! £324.99 on page 532 of its latest catalogue! children in the UK. This will require an Sir, — In response to the suggestion by Dr T J. Fieldhouse open and frank debate about how Nguyen that a bilateral ID block may make Weston-super-Mare effective dental care for young children treatment easier in some cases I would say. with caries is best provided. Such debate . . . rubber dammit! The claim that the Linda Wallace , BDA’s Director of will need to be informed by carefully treatment was much safer must be Professional Services says: designed prospective studies. Specifically, challenged. A bilateral ID block must The reviews show that the technique is safe we need to address the following surely leave a patient more vulnerable to and effective, but unfortunately, when the

BRITISH DENTAL JOURNAL VOLUME 193. NO. 6 SEPTEMBER 28 2002 300 UK legal position was tested, the House of to age, younger people prefer white teeth Lords decided that the supply of the when compared with their elders, while products was contrary to the EU Cosmetics the greatest concern for dental Directive and therefore illegal. It is a legal appearance was apparent in the middle technicality which turns on the aged (26-59 year olds) 6,7 classification of such products as Social class is also a factor. cosmetics and the limit on how much Paradoxically, even though the lower hydrogen peroxide a cosmetic product can socio-economic groups are seen to contain. The BDA is trying to resolve the traditionally neglect their teeth, they have issue both in the UK and Europe. a greater preference for white teeth, and a greater interest in dental appearance than Teeth whitening debate II those with higher levels of education.7,8,9 Sir, — I am writing regarding the current There is a balance to be struck. The situation with regard to dentists using trade-off between reduced incidence of tooth bleaching in their practices. I dental decay and increasing degrees of understand that my predecessor has fluorosis culminates in the Report’s indicated that dentists are allowed to use proposal to reduce levels of fluoride from techniques of external and of internal 1.00ppm to 0.80ppm. Given a favourable bleaching of teeth in any way provided outcome to the proposed efficacy study, that the patient or their carer agrees. then further judgements could be made These techniques themselves are not about the desirable concentrations of illegal. The highly publicised legal case fluoride additive to be used. revolved around the supply of these The general public has an increasing products and whether they are medical interest in dental appearance. Proper devices or cosmetic products. consideration of the unwanted effects of It is the Government's view that they fluoride on the broad sub-groups of our are cosmetic products. Notwithstanding population can only enhance our that, the Department of Health would not standing within the scientific community. seek to interfere with a dentist's It will also help us put our considered therapeutic decision to utilise a bleaching measured case to, what in water technique where a dentist considers this fluoridation terms, is a educated to be in the best interests of the patient's electorate. overall oral health care. M. Frazer Margaret Seward Twickenham Chief Dental Officer 1. Hawley G M, Eliwood R P, Davies R M. Dental caries, fluorosis and the cosmetic implications of different The York Report TF scores in 14-year old adolescents.Comm Den Sir, — The Report identifies a toxic effect Health 1996; 13: 189-192 of fluoride from all sources of intake, as 2. Riordan P J. Perceptions of dental fluorosis . J Den fluorosis of aesthetic concern. Self- Res 1993; 72:1268-1274 3. Kelly M. Steele J, Nuttall N, Bradnock G, Morris J, assessment of the cosmetic appearance of Nunn J, Pine C, PiUs N, Treasure E, White D. Adult such compromised teeth has not been Dental Health Survey 1998. investigated. 1,2 People can be expected to 4. Frazer M, Lindsay S. Development of a questionnaire to measure concern for dental appearance. Psych have views about the appearance of their Rep 2001; 89: 425-430 own teeth. There is every indication that 5. Burgersdijk R C W, Truin G-J, Kalsbeek H, Hof MA the background variables of gender, age, van92t, Mulder J. Objective and subjective need for cosmetic dentistry in the Dutch adult population. and social class are of importance when Comm Dent Oral Epidem 1991;19:61-63 discussing dental appearance and it is 6. Neuman L M, Christensen C, Cavanaugh C. Dental probable that ethnicity will also play a esthetic satisfaction in adults.. J Am Dent Assoc 1989; role. The scale of the problem of 118: 565- 570. 7. Vallittu P K, Vallittu A S J, Lassila V P. Dental blemished dentitions is described in the esthetics-a survey of attitudes in different groups of current Adult Health Survey where 27% people. J Dent 1996; 24: 335-338. of dentate adults are dissatisfied with the 8. Linn E L. Social meanings of dental appearance. J Health Hum Behav 1966; 7: 289-295. appearance of their teeth, and the most 9 Todd J F, Lader D. Adult Dental Health 1988 United common reason given (48%) for that Kingdom. Offices of Population Censuses and dissatisfaction is colour. These findings Surveys (Social Survey Division) London. tend to show little difference in attitude towards dental blemish among men and Aphthous ulcers women. However detailed study shows concern for dental appearance to be more Sir, — Many of us have had the displeasure important to dentate women than to being afflicted by aphthous ulcers, dentate men.4,5 Further, men tend to be although some of the suggested causes of less concerned with the appearance of aphthous ulcers have been a genetic their teeth having significantly more predisposition, link with natural missing teeth, crown defects and immunity, mouth injury following dental discolouration than women.6 With regard procedures or aggressive tooth cleaning,

BRITISH DENTAL JOURNAL VOLUME 193. NO. 6 SEPTEMBER 28 2002 301 when the tongue or cheek is bitten, stress, struggling registrar in 1974.2 providing the INR of the patient is dietary deficiencies such as iron, folic J. Townend below 4.1 To investigate if warfarin can be acid, or vitamin B12, menstrual periods, Chichester continued during dental extractions we hormonal changes, food allergies and recently performed a randomised drug treatment, there have been no 1. Stevenson RS, Guthrie D A History of Oto- controlled trial at Morriston Hospital in 2,3 laryngology. Edinburgh: Livingstone, 1949 2 suggested preventive measures. 2. Vincent-Townend J. Audiodontics- a case report. Swansea. 109 patients completed the trial Our personal observations over a period J Dentistry 1974; 2: 190-192 (see news item pg 306). covering the last twenty years suggest The incidence of bleeding episodes in that there may be a link between the the 57 patients who continued warfarin consumption of carton orange juice and Gingival recession during dental extractions was higher than aphthous ulcers. We have observed thirty- Sir, — I was interested to see the article by the 52 patients who stopped their six subjects of either sex between the age Messrs J. J. O'Dwyer and A. Holmes warfarin two days before extractions, but of 18 to 73 years who had recurrent showing gingival recession due to a lip this difference was not significant. Only 2 aphthous ulcers. stud. The clinical picture is very similar to out of 22 patients who had minor post- All consumed a quantity of orange that seen where there are crowded lower operative bleeding failed to control the juice daily. On being asked to refrain from incisors, where one lower incisor is bleeding at home by biting on gauze further orange juice consumption, ulcers labially displaced. squares. resolved in all subjects between one to The probable reason in both cases, is These two patients attended hospital five days without the use of any pressure from the lower lip against the where the bleeding was stopped by local medication. labial bone induces osteoclasis and the treatment of the extraction socket. Interestingly, the relapse occurred only resultant gingival recession. In the case of Therefore, although there may be some on the resumption of the use of carton the lip stud the artificial lump of metal increase in the number of patients orange juice. Equally, no ulcers occurred exerts localised pressure against the bone experiencing minor post-operative on eating fresh oranges, Halib-orange labial to the incisor. I suspect that if the bleeding when wafarin is continued, this tablets or drinking freshly prepared fruit lower incisors had been spaced the tooth does not appear to be a clinically juice. Our observations suggest that there in question would have moved lingually important problem. may be a link between the aphthous ulcer and there would have been no recession Ranstrom et al found that using formation and consumption of carton of the gingivae. tranexamic acid mouthrinses in patients orange juice, either due to a direct causal R.T. Broadway. who continued taking warfarin at the link or indirect aggravation of the buccal Winchester. time of dental extractions reduced mucosa in predisposed subjects. postoperative bleeding.3 However, The causative agent in the carton The authors respond: tranexamic acid does not have a product orange juice is not known.4 Therefore, it The aetiology of gingival recession is licence for use as a mouth rinse in the UK would be interesting to know if any other complex and multifactorial. The literature and can be used only for named patients.4 readers have made this observation. review we carried out prior to writing the Furthermore, the North West Medicines A. Ghelani, S. Mastana and A. Samanta article established a link, which for Information Centre advise that Loughborough obvious reasons we wished to highlight, Tranexamic Acid mouth rinse should not between trauma caused by tooth brushing be used in primary dental care.1 If 1. Reichart P A. Oral mucosal lesions in a representative and gingival recession.1,2,3 patients could be treated without altering cross-sectional study of aging Germans. Comm Dent Oral Epidemiol 2000; 28: 390-8. This evidence is however, gathered from their anticoagulant regimen, then it is 2. Pavelic J, Gall-Troselj K, Mravak-Stipetic M, Pavelic K. mainly retrospective cross-sectional possible that most dental extractions The p53 and nm23-H1 genes are not deleted in oral studies and case reports. There is no could be performed in general dental benign epithelial lesions. Anticancer Res 1998; 18: 3527-31. doubt that gingival recession occurs much practice on the same day as regular INR 3. Boulinguez S, Reix S, Bedane C, Debrock C, more readily when there is an underlying blood monitoring. This would often be Bouyssou-Gauthier M L, Sparsa A, et al. Role of drug bony deficiency. more convenient and quicker for the exposure in aphthous ulcers: a case-control study. Such deficiencies can be caused by patient, cost effective, and help to reduce Br J Dermatol 2000; 143: 1261-5. 4. ANONYMOUS. Citrus: It Only Begins wIth C. orthodontic treatment. As we stressed in hospital waiting lists. It remains to be University of California at Berkeley Wellness Letter the article, however, dehiscence is much established if our study's findings can be 2000; 17:1-2 more likely to occur during orthodontic translated to general dental practices. A word in your ear therapy when there are no teeth extracted A. J. Gibbons, I. L. Evans, M. S. Sayers, G. and the lower incisors have been Price, H. Snooks, A. W. Sugar Sir, — I was intrigued by your news item proclined, this was not the case. Swansea (BDJ 2002; 193: 130) concerning a prototype tooth implant capable of 1. Wennström J, Pini Prato G P. Mucoginival Therapy. 1. Surgical Management of the Primary Care Dental Clin Perio Imp Dent: 554. Munksgaard, 1998. Patient on Warfarin. transmitting audio messages to the inner 2. Khocht A, Simon G, Person P, Denepitiya J L.. Gingival www.ukmi.nhs.uk/med_info/documents/Dental_Pat ear via the jaw bone. Recession in Relation to History of Hard Toothbrush ient_on_Wafarin.pdf The ability of the teeth to act as a sound Use. J Perio 1993; 64: 900-905. 2. Evans I L, Sayers M S, Gibbons A J, Price G, Snooks H, Sugar A W. Can Warfarin be continued during dental conduction apparatus has, of course, been 3. Wennström J. Lack of association between width of attached gingiva and development of soft tissue extractions? Results of a randomised controlled trial. recognised for many years. recession. A 5-year longitudinal study. J Clin Perio Br J Oral Maxillofac Surg 2002; 40: 248-252 Volcher Coiter (1572) observed that the 1987; 14: 181-184. 3. Evans I L, Sugar A W. Re Webster K, Wilde J. Management of anticoagulation in patients with sound of a musical instrument becomes prosthetic heart valves undergoing oral and louder when clenched between the teeth Warfarin and extractions maxillofacial operations. Br J Oral Maxillofac Surg and Joseph Guichard Duverney explained 2000; 38: 124-126. 4. Ramstrom G, Sindet-Pedersen S, Hall G, Blomback M, the mechanism of bone conduction of Sir, — The North West Medicines Alander U. Prevention of postsurgical bleeding in oral 1 sound in 1683. Information Centre recommends that surgery using tranexamic acid without dose Interested readers may care to look up a warfarin does not need to be stopped modification of oral anticoagulants. J Oral Maxillofac brief case report I wrote when a before dental surgical procedures Surg 1993; 51: 1211-1216.

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